RESEARCH ARTICLE
SSccrreeeenniinngg ffoorr A Allccoohhooll aannd d D Drruuggss ooff A Abbuussee iinn T Trraauum maa V
Viiccttiim mss
Banuçiçek YÜCESAN*, fiebnem fi. ÇEÇEN**, Yücel DENER***, Rüçhan ÖZTÜRK***, Yaflar B‹LGE****, Tülin SÖYLEMEZO⁄LU**°
Screening forAlcohol and Drugs of Abuse in Trauma Victims Summary
The objective of this study was to evaluate the relationship bet- ween alcohol/drug abuse and injury severity caused by trauma.
Toward this aim, routinely collected urine and blood specimens from 102 trauma patients were analyzed for the presence of drugs of abuse by an enzyme immunoassay method, CEDIA® DAU, and for alcohol by headspace gas chromatography. To predict recovery, to assess the patient’s condition and to deter- mine the possible correlation between alcohol/drug abuse and injury severity, trauma score (TS), Glasgow coma scale (GCS) and % probability of survival were calculated. Our results de- monstrated that male patients were more likely to use drugs and consume alcohol than female patients (p= 0.001). Tra- uma victims with severe and fatal injuries having low TS and GCS with low probability of survival were more likely to have positive screens (p=0.000) and higher blood alcohol levels (p=0.000) than those with less severe injuries. However, no sig- nificant relationship was found between alcohol/drug abuse and trauma reasons (p=0.061) or between trauma reasons/sex (p=0.078)
K
Keeyy WWoorrddss :: Alcohol and abused drugs, trauma score, Glas- gow coma scale, CEDIA®DAU, headspace gas chromatography
Received : 17.05.2005 Revised : 03.10.2005 Accepted : 05.10.2005
Travma Kurbanlar›nda Alkol ve Ba¤›ml›l›k Yapan Maddelerin Araflt›r›lmas›
Özet
Bu çal›flman›n amac›, alkol/madde ba¤›ml›l›¤› ile travma sonu- cu ortaya ç›kan yaralanman›n ciddiyeti aras›ndaki iliflkiyi de-
¤erlendirmektir. Bu amaçla, 102 travmal› hastan›n rutin olarak toplanan kan ve idrar örneklerinde, enzim immunoassay yön- temi, CEDIA® DAU ile madde ba¤›ml›l›¤› ve headspace gaz kromatografisi yöntemi ile alkol analizi yap›lm›flt›r. Hastalar›n sa¤l›k durumlar› ile ilgili yorum yapabilmek ve alkol/madde kullan›m› ile yaralanman›n ciddiyeti aras›ndaki olas› iliflkiyi ayd›nlatabilmek amac›yla travma skoru (TS), Glasgow koma skoru (GKS) ve % kurtulma olas›l›klar› hesaplanm›flt›r. Sonuç- lar›m›z göstermektedir ki; erkek hastalar›n madde ve alkol kul- lanma olas›l›klar› kad›n hastalara göre daha fazlad›r (p=0.001). Yap›lan analizlerde ciddi ve ölümcül yaralanmala- r› olan ve TS, GKS ve % kurtulma olas›l›klar› düflük olan has- talarda daha hafif travmas› bulunan hastalara oranla daha çok pozitif sonuç al›nm›fl (p=0.000) ve yüksek kan alkol dü- zeyleri (p=0.000) tespit edilmifltir. Ancak alkol/madde ba¤›m- l›l›¤› ve travma nedenleri (p=0.061) ile travma nedenleri-cinsi- yet (p=0.078) aras›nda istatistiksel bir farkl›l›k bulunamam›fl- t›r.
A
Annaahhttaarr KKeelliimmeelleerr :: Alkol ve madde ba¤›ml›l›¤›, travma skoru, Glasgow koma skoru, CEDIA® DAU, headspace gaz kromatografisi.
IINNTTRROODDUUCCTTIIOONN
Alcohol consumption and drug addiction are incre- asing in incidence throughout the world in conjunc-
tion with increasing social, psychological and legal problems. They are also considered to be one of the major causes of all types of trauma1.
* Refik Saydam Hygiene Center, Blood and Blood Products Quality Control Laboratory, Ankara, TURKEY.
** Ankara University, Institute of Forensic Medicine, 06260, Dikimevi, Ankara, TURKEY.
*** The Rebuplic of Turkey, Ministry of Justice, Council of Forencis Medicine, Chemistry Department, Ankara, TURKEY.
**** Ankara University, Faculty of Medicine, Department of Forensic Medicine, Dikimevi, Ankara, TURKEY.
° Corresponding author e-mail: [email protected]
tablishing a differential diagnosis and developing a management plan10.
This study was undertaken at the Ministry of He- alth, Ankara Education and Research Hospital, Emergency Service, to evaluate the prevalence of drug abuse and alcohol consumption in trauma pa- tients and to investigate the possible relationship between dependence and severity of injury.
M
MAATTEERRIIAALLSS AANNDD MMEETTHHOODDSS P
Paattiieennttss aanndd SSaammpplleess
One hundred and two traumatized patients aged 16 years and over admitted to the Ministry of Health, Ankara Education and Research Hospital, Emer- gency Service were evaluated. With the consent of each patient, not less than 5 cc of blood was drawn from antecubital region under appropriate and ste- rile conditions by the hospital’s professional emer- gency nurses into tubes containing EDTA and sto- red at +4°C for alcohol determination; urine was col- lected for general toxicology screening. Patients we- re coded by a protocol number. This study was app- roved by the Ethic Council of Ankara University (15.06.2000, No: 06-2000/57).
Assessment of the Severity of Injury, Trauma Sca- ling System
Age, sex, cause of injury and physiological data ne- cessary for the calculation of GCS and TS were col- lected (Table 1). Percent probability for survival for each total trauma score is given in Table 2.
TTaabbllee 22.. Percent probability of survival for each tra- uma score11
T
Toottaall %%PPrroobbaabbiilliittyy SSccoorree ooff SSuurrvviivvaall
16 99
15 98
14 95
13 91
12 83
11 71
10 55
9 37
8 22
7 12
6 7
5 4
4 2
3 1
Under 3 0
Trauma is evaluated as the leading cause of deaths and disabilities encountered particularly in the yo- ung and productive population2, which can contri- bute to a great burden of socioeconomic problems in developing countries3.
Many trauma scoring systems based on physiologi- cal data, anatomic injuries, or both have been repor- ted4. These systems are used for trauma triage, which in brief is a method of categorizing patients by classifying them according to severity of injury and of managing the patients to ensure they are tre- ated via the most appropriate and efficient route5. Trauma score (TS) is a physiological grading system to estimate the recovery and the probability of sur- vival of each individual6. It includes Glasgow coma scale (GCS) based on the ratings of eye movements, verbal and motor responsiveness7, respiratory rate, systolic blood pressure and capillary refill8(Table 1).
TTaabbllee 11.. Numerical grading system for estimating the severity of injury8
G
Gllaassggooww CCoommaa SSccaallee TTrraauummaa SSccoorree
Eye Opening Spontaneous 4 Total Glasgow 14-15 5 To Voice 3 Come Scale Points 11-13 4
To Pain 2 8-10 3
None 1 5-7 2
3-4 1
Verbal Response Oriented 5
Confused 4 Respiratory Rate 10-24/min 4 InappropriateWords 3 24/35/min 3 Incomprehensible 2 36 min or greater 2
Words 1-9 min 1
None 1 None 0
Motor Response Obeys Command 6
Localizes Pain 5 Systolic Blood 90 mmHg or greater 4 Withdraw (Pain) 4 Pressure 70-89 mmHg 3 Flexion (Pain) 3 50-69 mmHg 2 Extension 2 0-49 mmHg 1
None 1 No Pulse 0
Total GCS Severe head injury Under 8
and coma Capillary Refill Normal 2
Moderate 9 -12 Delayet 1
Mild 13-15 None 0
T
Toottaall TTrraauummaa SSccoorree 11--1166 Although there is still much debate on routine toxi- cological screening of trauma patients because of its high cost9, traumatologists pronounce it useful in es-
A
Annaallyyssiiss ooff BBlloooodd AAllccoohhooll CCoonncceennttrraattiioonn ((BBAACC)) The gas chromatograph (GC) was an HP 5890 series II gas chromatograph with a flame ionization detec- tor (FID), equipped with an HP 7694 Headspace Sampler. A 30 m x 0.53 mm x 0.1 mm Hewlett Pac- kard (HP-FFAP) column was used. The GC oven temperature was initially 40°C for 3 mins., ramping at 100C/min. to a final temperature of 70°C and held for 2 mins. at this temperature. The GC had an injec- tion temperature of 225°C and a detector temperatu- re of 250°C. Standards were prepared with incre- asing ethanol concentrations: 160, 320, and 480 mg/dl. An internal standard (IS), 80 mg/dl n-buta- nol, was added to each standard solution. All stan- dards and test solutions were prepared in water, and 1 ml aliquots of each standard and 0.5 ml of IS were transferred to 10 ml headspace vials. The calib- ration curve is given in Figure 1. One ml of whole blood was used for the analyses.
FFiigguurree 11.. Graph representing ethanol calibration.
U
Urriinnee DDrruugg TTooxxiiccoollooggyy SSccrreeeenn
Urine samples were analyzed for drugs of abuse (benzodiazepines, barbiturates, cocaine, ampheta- mines, opiates, tetrahydrocannabinol-THC and 6- acetylmorphine) using a commercial enzyme immu- noassay screening method, Cloned Enzyme Donor Immunoassay, CEDIA®DAU (Table 3).
T
Taabbllee 33.. CEDIA® DAU urine cut-off values and amount of automatic injections for each drug
U
Urriinnee CCuutt--ooffff AAmmoouunntt ooff V
Vaalluueess ((nngg//mmll)) AAuuttoommaattiicc IInnjjeeccttiioonn Benzodiazepine derivatives 200 3 ml
Barbiturates 200 9 ml
Cocaine metabolites 300 6 ml
Amphetamines 1000 6 ml
Opiates (Morphine-Codeine) 300 3 ml Cannabinoids metabolites (THC) 50 6 ml SSttaattiissttiiccss
Statistical differences between the groups of alco- hol/drug abuse-sex, alcohol/drug abuse-trauma re- asons and sex-trauma reasons were evaluated by chi-square analysis, whereas the differences stated between alcohol/drug abuse-injury severity scores and alcohol/drug abuse-age were tested using one- way analysis of variance (ANOVA) method. In ad- dition, Pearson’s correlation was used to determine the association between injury severity scores-blood alcohol level (BAL) and –age. Statistical Package for Social Sciences (SPSS 11.5) was used to calculate all the statistical procedures in the current study. P va- lues <0.05 were considered significant.
R
REESSUULLTTSS AANNDD DDIISSCCUUSSSSIIOONN
Clinical and epidemiological studies done in the last fifty years have demonstrated that traumatic events and accidents have sheltered drug abuse criteria, es- pecially alcohol consumption. Individuals lose their abilities and reflexes, mostly while driving and also in their social lives, when they are under the influen- ce of drugs and/or alcohol1,12,13.
It is evident that individuals abusing drugs/alcohol are at risk of trauma and especially are more likely to be involved in traffic accidents when compared with the general population1,9,12. A correlation has also been reported between age and drug abuse12. Cocaine, marihuana, opiates and alcohol have been frequently detected/co-detected in trauma vic- tims14,15,16,17. Significant attention has been given in the past and is continuing to enlighten drug abuse criteria throughout the world. However, we pre- sently have very limited data in this regard, and most of the studies depend on oral questionnaires rather than reliable toxicological analyses.
In the current study, 102 patients with trauma injuries, who were admitted to the Ministry of Health, Ankara Education and Research Hospital, Emergency Service during a five-month period were screened for blood al- cohol by gas chromatography with flame ionization detector and for drugs of abuse with an enzymatic im- munoassay method, CEDIA®DAU.
Age of patients ranged from 16 to 80 and above, with a mean of 37.42±13.20 years. The mean age of female patients (n=22) was 36.40±13.12 years and of male patients (n=80) 41.14±13.10 years. Age groups of all patients with major trauma are demonstrated in Figures 2 and 3 according to sex. When patients were grouped according to drug/alcohol abuse cri- teria it was found that Group A patients (negative screen, n=61) had a mean age of 38.28±14.00, while in Group B patients (positive screen, n=41), this va- lue was calculated as 36.15±11.95 years. No statisti- cally significant difference was observed between the groups based on age.
FFiigguurree 22..Age groups of the total patient population accor- ding to sex.
FFiigguurree 33.. Age groups of patients with positive screen ac- cording to sex.
0 2 4 6 8 10 12
Patients with positive screen
##ooff PPaattiieennttss
total 2 4 11 8 8 4 1 3
male 2 4 11 7 8 3 1 3
female 0 0 0 1 0 1 0 0
16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-80
Age Groups
0 5 10 15 20 25 30
## ooff PPaattiieennttss
Total 1 6 8 25 15 16 12 7 12
Male 1 6 7 20 12 14 8 5 9
Female 0 0 1 5 3 2 4 2 3
<16 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-80
Although a study constructed by Lopez-Rivadulla et al.18demonstrated no association between traffic ac- cidents and sex or age, many studies have shown that mostly men aged between 20-35 were involved in traumatic events15,19,20. Our results are consistent with these results. We observed a significant diffe- rence regarding sex and abused drugs (p=0.001).
Only 4.9% of the patient group with positive result was female, which also reflects the social status of females in our society.
The type of trauma involved in the present study co- vered a wide spectrum, including work- related and traffic accidents, falls, stabbings, gunshot wounds and strokes. No significant association was found between drug abuse and the indicated traumas, with the exception of falls (Table 4).
T
Taabbllee 44.. Frequencies of trauma reasons according to drug/alcohol abuse criteria and sex
SSeexx GGrroouupp AA GGrroouupp BB XX22 PP Traffic accidents Male 19 20 1.998 0.226a
Female 14 1
Total 33 21 0.375 0.551b
Falls Male 6 1 0.466 0.446a
Female 3 0
Total 9 1 4.205 0.047*b
Strokes Male 5 6
0.000 1.000a
Female 2 1
Total 7 7 0.649 0.559b
Gunshot wounds Male 1 2
0.850 1.000a
Female 0 0
Total 1 2 0.901 0.563b
Stabbings Male 8 10
3.313 0.111a
Female 1 0
Total 9 10 2.145 0.187b
Work-related Male 2 0
0.561 1.000a
Female 0 0
Total 2 0 1.371 0.514b
aStatistical differences found between the groups of trauma reason and sex. bStatistical differences found between the groups of tra- uma reason and drug/alcohol abuse criteria. Group A= patients with negative screen; Group B= patients with positive screen.
The significant relationship found between falls and drug abuse (p=0.047, p<0.005) showed that patients with negative screen (n=9) were more likely to fall when compared to positive screened patients (n=1), which can indicate that people abusing drugs and alcohol have a tendency to withdraw from social li- fe. Since no statistically significant relationship was found when trauma reasons were examined in six
different groups, causes of trauma were regrouped under two titles, as "accidental injury" and "violent crime". Traffic accidents, falls and work-related inju- ries were considered accidental injuries, whereas stabbings, gunshot wounds and strokes were classi- fied as violent crime. These two groups were reeva- luated based on drug abuse (Table 5) and may be considered as statistically different (p=0.061) since the difference found was very close to the limit of significance, i.e. p<0.05 as stated previously.
T
Taabbllee 55.. Frequencies of accidental injury and vi- olent crime according to drug/alcohol abu- se criteria and
SSeexx GGrroouupp AA GGrroouupp BB XX22 PP Accidental Injury Male 27 21 3.597 0.078a
(AI) Female 17 1
Total 44 22
Violent Crime Male 14 18 3.664 0.061b
Female 3 1
Total 17 19
aStatistical differences found between the groups of AI/violent crime and sex.
bStatistical differences found between the groups of AI/violent crime and drug/alcohol abuse criteria.
Group A= patients with negative screen; Group B= patients with positive screen.
Although accidental injuries (53.7%) and violent cri- mes (46.3%) were approximately equal in the positi- ve-screened group, traumas were more likely to be accidental injuries (72.1%) rather than violent crime (27.9%) in Group A.
No statistically significant relationship was found between trauma reasons (AI and violent crime) and sex parameters (p=0.078). However, if only the fe- male population was considered, it is evident that the frequency of accidental injury (81.8%) was more than that of violent crime (18.2%). Male patients we- re involved in violent crime (88.9%) more than fema- le patients (11.1%) if the whole population was exa- mined (Table 5). When all trauma reasons were exa- mined according to sex individually, no significant relationship was observed. However, if only the fre- quency of traffic accidents was considered accor- ding to sex, female population (n=15) is noticeable
(68.2%) when compared to the whole female popu- lation encountering other traumatic events (n=22).
Patients were also defined by their TS and probabi- lity of survival as seen in Table 6.
T
Taabbllee 66.. GCS, TS and % probability of survival for trauma victims according to drug/alcohol abuse criteria
GGrroouupp AA GGrroouupp BB XX22 PP Glasgow <8 (severe) 1 11 8.333 0.004 Coma Scale 9-12 (moderate) 22 26 0.333 0.564 (GCS)
13-15 (mild) 38 4 27.524 0.000
Total 61 41 33.559 0.000*
0-9 (0-37%)
Total Trauma High risk 1 17 14.222 0.000 Score (TS) & 10-16 (55-99%)
(%Probability Medium&low 60 24 15.429 0.0000 of Survival) risk
Total 61 41 26.758 0.000*
* Statistical differences between all the subgroups of GCS and to- tal TS and drug/alcohol abuse criteria.
Group A= patients with negative screen; Group B= patients with positive screen.
Negative screened patients with major trauma (n=61) had GCS scores of 12.46±1.20, indicating that patients in this group had moderate injuries (Table 7). On the other hand, this score decreased to 9.76±2.16 in Group B patients. Even though both of the groups fall into the same category (Range: 9-12, GCS Score - Moderate injury, Table 1), the differen- ce between them was found to be statistically signi- ficant (p=0.000). Trauma scores of Group A and Group B patients were calculated as 13.61±1.50 and 9.61±2.34, respectively. Furthermore, Group A pati- ents had a mean of % probability of survival of 90.70±11.34, while Group B patients had a mean of 49.78±28.17 (Table 7). It is apparent that there is a sharp decrease in both TS and % probability of sur- vival in Group B patients (p=0.000, Table 7).
The data obtained and explained above are used for trauma triage throughout the world. Triage is a met- hod of classifying the injured patients according to their severity of injury, by which every patient is managed to the right trauma center depending on his level of need5. Unfortunately, no such centers are available in Turkey. In fact, every patient is taken to the nearest hospital’s emergency service, where the physicians decide whether there is a need for a transfer to a more specialized hospital. Trauma cen- ters and pre-hospital triage systems are established on the idea of decreasing morbidity and immedi- ately operating any critically injured patient4. Our results demonstrated that of the 102 patients who received toxicological screening, 40.19% tested positive for alcohol only, with BAC’s ranging from 25-344 mg/dl. Among positive BAC’s, 68.29% were 100 mg/dl or higher. Such high levels were found only in male victims. Moreover, only two female pa- tients (n=22) tested positive for alcohol, and the le- vels detected were only 20 and 60 mg/dl, from which it can be assumed that alcohol was not the ca- use of trauma in these two cases. The results of blo- od alcohol analysis, (if considered for the whole pa- tient population) showed that as BAC increases, GCS, TS and % probability of survival decrease (Table 8). In addition, no association was found bet- ween age and injury severity scores. However, these parameters were observed to be inversely correlated (Table 8).
T
Taabbllee 88.. Associations found between injury severity scores-age and injury severity scores-blood alcohol level.
AAggee BBlloooodd AAllccoohhooll LLeevveell ((BBAALL))
Glasgow Coma r -0.028 -0.650
Scale (GCS) P 0.780 0.000*
Trauma Score (TS) r -0.026 -0.681
P 0.796 0.000*
% Probability r -0.053 -0.652
of Survival P 0.598 0.000*
*p<0.001
In the present study, drugs of abuse were detected in the urine of only four victims. We have to take in- to consideration that drug abusers encountered in the current study were all involved in violent crime, whereas the studies demonstrated in other countri- es have shown that it was possible to detect cocaine and benzodiazepines even in a simple traffic acci- dent10,21,22. Detection of barbiturates, benzodiazepi- nes and opiates in urine of trauma victims high- lights that priority should be given to the detection of these drugs in toxicological screening.
As a result, we believe that this study is an impor- tant approach to the relationship between drug/al- cohol abuse and trauma in our country; however, further investigations must be done with larger samples to further enlighten the problem and redu- ce the personal, social and economic burden caused by substance and drug abuse.
A
Acckknnoowwlleeddggeemmeenntt
This research was supported by DPT (98K 120820) T
Taabbllee 77.. Glasgow coma scale (GCS), trauma score (TS) and % probability of survival values, means, standard deviations, F and P values for trauma victims according to accidental injury-violent crime and drug/alcohol abuse criteria
AAcccciiddeennttaall IInnjjuurryy VViioolleenntt CCrriimmee TToottaall
GGrroouupp AA GGrroouupp BB FF GGrroouupp AA GGrroouupp BB FF GGrroouupp AA GGrroouupp BB FF ((nn==4444)) ((nn==2222)) ((nn==1177)) ((nn==1199)) ((nn==6611)) ((nn==4411))
GCS 12.48±1.15** 9.5±2.52 43.68* 12.41±1.37 10.05±1.68 20.94* 12.46±1.20 9.76±2.16 65.21*
TS 13.93±1.26 9.31±2.78 86.28* 12.76±1.75 9.95±1.71 23.74* 13.61±1.50 9.61±2.34 110.55*
% Prob. of
Survival 93.23±6.66 46.68±31.94 87.15* 84.18±17.32 53.37±23.40 19.75* 90.70±11.34 49.78±28.17 104.09*
* P=0.000
** mean ± standard deviation
and Ankara University (Scientific Research Project no: 20010000004).
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